Keeping Kids Alive: A Report on the Status of Child Death ... · Trends in Child Death Review The most notable indicator of growth of the CDR system is that today there are more than

Keeping Kids Alive:

A Report on the Status of Child Death Review in the United States

2017

Source of Information:

The National Center for Fatality Review and Prevention State Profile Database:

Reports from State Child Death Review Program Coordinators

1-800-656-2434 Email: [email protected]

1825 K Street, NW Washington, DC, 20006

www.ncrfp.org

©Michigan Public Health Institute, October 2018

This guidance was made possible in part by Cooperative Agreement Number UG7MC28482 from the US Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB) as part of an award totaling $799,997 annually with 0 percent financed with non-governmental sources. Its contents are solely the responsibility of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

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Introduction

ach year almost 40,000 children, ages 0-18, die in the United States. Child Death Review (CDR) is a

process in which multidisciplinary teams of people meet to share and discuss case information in order

to understand how and why children die. The ultimate goal of a CDR team is to take action preventing

future deaths. Every state and the District of Columbia has a CDR system. Throughout the United States,

however, these systems differ in their scope at both the state and local level. States vary in composition of state

and local teams, level of state support, placement of administrative leadership, supporting legislation, the types of

deaths reviewed, and reporting systems. Every state has an agency and a person designated as the lead for its CDR

program.

The National Center for Fatality Review and Prevention (National Center) conducts an annual query of state CDR

program leaders to assess the status of their programs. The following tables are a synopsis of the responses and

represent the status of the programs in calendar year 2017. Nine states did not reply to the query for a variety of

reasons, so the data presented for those states are based on the most recent year they did respond; those states

are Alabama (2016), California (2013),Indiana (2016), Maine (2016), Mississippi (2016), Rhode Island (2016), Utah

(2015), Washington (2016), and Wyoming (2016).

The information in the following tables is not static, as states often make improvements to their programs, adopt

new legislation to support their programs, or build new teams; but the following information provides a

comprehensive snapshot of the status of CDR in the United States. More complete information and links to

individual state programs can be found on the National Center website (www.ncfrp.org).

Trends in Child Death Review

The most notable indicator of growth of the CDR system is that today there are more than 1,350 state and local

teams in all 50 states and the District of Columbia, and teams in Guam and the Navajo Nation. Shoshone-Bannock

Tribe is exploring building a team in 2018. State CDR budgets and staffing levels steadily increased between 2004

and 2008, and then decreased as state economies struggled.

The number of states with state statutes and regulations governing CDR rose to 45 in 2015. While there is no

change this year, Vermont slightly modified their CDR legislation in 2017. The number of states with statutes or

regulations that cover the following protocols for CDR review continues to stay steady: confidentiality of CDR

meetings, access to records, privacy of review meetings, protection of reviews from subpoenas/discovery and

FOIA, CDR program reports, designation of required state and local team members, and required review protocols.

Each of these provisions is important to the integrity of the CDR process.

The scope of CDR varies from state to state. Throughout the country, more than ever before, state-level teams are

now reviewing deaths from sudden and unexplained infant deaths (SUID), unintentional injuries, suicide, homicide,

abuse and neglect, and the deaths of children who were wards of the state or had a history with child protective

services. There has also been an increase in the number of local teams that review medical deaths (e.g., deaths

from infection, asthma, cancer, cardiac issues), SUID, unintentional injuries, homicides, suicides, and abuse and

neglect. When teams review medical deaths, they all too often uncover medical neglect, a strong argument for

reviewing all child deaths. Thirteen states report that they review all child deaths.

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The average time between the death and the review increased slightly at the local and state level. Of the states

that reported this figure this year, three reported a longer time for local teams; two reported a shorter time; the

rest had no change. With respect to state teams, one dropped slightly in the time between death and review; six

increased slightly, and the rest were unchanged.

The movement of CDR toward a prevention model was reflected for a number of years by the movement of state

CDR programs from Social Services into public health. No matter where they are housed, most teams have a strong

focus on secondary prevention and systems improvements. Forty-three states (up from forty-two last year) have

advisory boards that make prevention recommendations to state officials and the public.

Another important aspect of CDR is the data obtained from reviews. Teams enter data about the circumstances of

each death they review into reporting systems and use the data to develop and implement evidence-based

initiatives to reduce child death. In 2005, the National Center initiated its web-based National Fatality Review Case

Reporting System (NFR-CRS) and made it available at no cost to all local and state teams. Since 2017, 44 states and

their local teams have participated in the NFR-CRS; each of the other six states uses a different system, usually

state-specific. In 2017, 43 states reported that they used their CDR data to produce Annual Reports. There are now

more than 200,000 cases entered into the system, and state and local teams use the data to identify risk and

protective factors in child deaths.

To make this rich data resource available for further analysis and study by child health and safety researchers, the

National Center developed a Data Dissemination Policy and procedures, through which researchers can apply to

use the data, and appointed an external committee of scientists, CDR coordinators, and our federal partners to

review research applications. Articles by researchers who used the data in the case reporting system are now

being published, contributing to knowledge about how and why children die.1

The National Center encourages CDR programs to coordinate and collaborate with other types of death reviews

and for the past three years has surveyed states about those efforts. The number of states that collaborate with

other types of reviews (FIMR, domestic violence, maternal mortality, and others) increased slightly this year.

Additionally, this year we asked a new question about whether child abuse and neglect deaths in the states are

reviewed by other entities than the state or local CDR team (Table 37).

In 2015, the Center’s funder, HRSA/MCHB, determined it would fund a single data center for both CDR and FIMR.

The National Center competed for and was awarded the funding for the merged center. The merger has increased

1 A sample of recent articles based on NFR-CRS data: Krugman, S. D., & Cumpsty-Fowler, C. J. (2018). A hospital-based initiative

to reduce postdischarge sudden unexpected infant deaths. Hospital Pediatrics,8(8), 443-449. doi:10.1542/hpeds.2017-0211.

http://hosppeds.aappublications.org/content/8/8/443; Burns KM et al. (2017). The Sudden Death in the Young

Case Registry: Collaborating to Understand and Reduce Mortality. Available first online: http://pediatrics.aappublications.org/content/early/2017/02/20/peds.2016-2757; Parrish J et al. (2017).Classification of Maltreatment-Related Mortality by Child Death Review Teams: How reliable are they? Child Abuse & Neglect Final version published online: 30-Mar-2017 DOI information: 10.1016/j.chiabu.2017.03.003. http://www.sciencedirect.com/science/article/pii/S0145213417300959; Scheers NJ, et al. (2016). Crib bumpers continue to cause infant deaths: A need for a new preventive approach. Pediatrics 169: 93–97.e1; Triclylidas T, et al. (2016). Pediatric Suicide in the United States: Analysis of the National Child Death Case Reporting System. Injury Prevention 0:1–6; http://pediatrics.aappublications.org/content/early/2017/02/20/peds.2016-2757; Erck AB et al. (2016). Death Scene Investigation and Autopsy Practices in Sudden Unexpected Infant Deaths. J Pediatrics; 174:84-90. https://www.researchgate.net/publication/301671583_Death_Scene_Investigation_and_Autopsy_Practices_in_Sudden_Unexpected_Infant_Deaths. Abstract only.

http://pediatrics.aappublications.org/content/early/2017/02/20/peds.2016-2757

http://www.sciencedirect.com/science/article/pii/S0145213417300959

http://pediatrics.aappublications.org/content/early/2017/02/20/peds.2016-2757

https://www.researchgate.net/publication/301671583_Death_Scene_Investigation_and_Autopsy_Practices_in_Sudden_Unexpected_Infant_Deaths

https://www.researchgate.net/publication/301671583_Death_Scene_Investigation_and_Autopsy_Practices_in_Sudden_Unexpected_Infant_Deaths

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opportunities for collaboration among CDR and FIMR teams, and the Center has a staff person dedicated to

helping improve CDR and FIMR collaboration in states. A separate report on the Status of FIMR teams is also

available from the Center.

The Department of Defense (DOD) has an active child death review program for deaths of children of active service

members. The Center has worked with DOD for a number of years to facilitate collaboration between military child

death reviews and CDR reviews in the communities where the death occurred. There are 13 states where the

military participates on local and/or state teams, and eight states where local and/or state CDR teams partner with

the military teams on their reviews.

Looking Forward

DATA

In 2018, the National Fatality Review Case Reporting System (NFR-CRS) was updated to Version 5.0. With the

merger of the centers, the National Center is serving as the national data resource center for both CDR and FIMR.

Version 5.0 added a FIMR module so that any FIMR team will be able to enter and analyze data in the same way

the CDR teams currently can.

Forty-four states and their local teams participate in the NFR-CRS. Considering that participation in the system is

voluntary and states are not financially compensated for participating, the commitment by 44 states to submit

their review data into a national database is nothing short of extraordinary and unprecedented.

The purpose of the NFR-CRS is to learn from the data to prevent further deaths. In the coming year, the National

Center will begin publishing a series of reports summarizing and analyzing the data about specific types of death.

The purposes of the reports are to broaden availability of summary data from child death reviews and to inform

prevention policies and activities in the states and nationally.

The Center is also working in partnership with the U.S. Centers for Disease Control and Prevention (CDC) to

implement a Sudden and Unexpected Infant Death (SUID) Case Registry in 18 states, and with the CDC and the

National Institutes of Health on a Sudden Death in the Young (SDY) Case Registry in 10 states. The states (or their

jurisdictions) use the NFR-CRS as the foundation for reporting 100% of their SUID and/or SDY deaths into these

registries.

PREVENTION

In 2018, the Center will continue its focus on prevention activities. CDR teams are working hard to craft better

recommendations and implement evidence-based and promising practices that can prevent child deaths. The

National Center is proud of and excited by the prevention activities taking place around the country as a result of

CDR activities and will continue to provide states with links to resources to support their prevention work and to

showcase programs that have moved from reviews to effective child safety, health, or injury prevention outcomes.

THE REVIEW PROCESS

With funding support from HRSA’s Maternal and Child Health Bureau, the National Center strives to help states

improve their CDR systems. Part of this work is helping states standardize their fatality review practices while also

valuing the state and local contexts in which the reviews function. In the next year, the Center will continue to

support the states as they work to improve their capacity to review more types of deaths and grow their local

teams and will continue its provision of on-site technical assistance and training to states. The Center will also

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continue its work with Guam, other Pacific Island nations, Puerto Rico, and with the Navajo Nation and other

Indian tribes as they build their CDR programs.

The National Center will continue its initiatives to increase coordination between FIMR and CDR; to improve the

quality of the data in the Case Reporting System; and to assist states to address health inequities through reviews.

The Center also hopes to work with experts to develop a more formalized structure to review maltreatment deaths

with a focus on improving agency systems.

An additional system to support state CDR programs by region was developed in 2011. The five regions (New

England, Southeast, Midwest, West, and Mid-Atlantic) held meetings of state coordinators and other interested

CDR leaders in 2012, 2013 and 2014, 2015, and 2016. All five regions participated in a national meeting in Denver,

Colorado in May, 2018. The regions will meet again separately in Spring 2019. These meetings allow states the

opportunity to network and share strategies for improving the power of CDR to move from reviews to prevention.

NATIONAL PARTNERSHIPS

Increasingly, national organizations are connecting to CDR at a local, state and national level. A number of agencies

are working to utilize CDR data to better understand SUID, drowning deaths, suicides, child maltreatment, deaths

from consumer product failures, maternal mortality review, and motor vehicle deaths. The National Center is a

member of several national coalitions to help translate our work into prevention at the national policy level. States

also report important partnerships with a variety of partners, including those working in injury prevention,

maternal and child health, SUID and SIDS, child abuse, and disability advocacy.

The Center is also developing new partnerships with public health epidemiologists and statisticians; university

researchers; elected officials; Medicaid officials; district attorneys; juvenile justice agencies; highway safety

programs; emergency medical services; fire marshals; and mental health, suicide, and education agencies.

All efforts to improve CDR are possible because of the dedication of state CDR leaders and the thousands of

professionals and child advocates who attend state and local review meetings. Their participation on more than

1,350 local teams and 43 state boards is a key reason that CDR has become a powerful system to help Keep Kids

Alive.

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Tables/Charts Describing the Status of CDR in the U.S.

SECTION A: CDR PROGRAM ADMINISTRATION ....................................................................... 7

1. State Agency That Leads Coordination of CDR Program ..................................................... 8

2. State Agency That Leads Coordination of CDR Program by State ....................................... 8

3. Type of State CDR Coordination and Program Support .................................................... 10

4. CDR Coordination with Other State Programs .................................................................. 10

5. Annual Funds Allocated Specifically for CDR Programs by State ....................................... 11

6. Type and Source of Funding Allocated for CDR Programs by State .................................. 11

7. Paid Staff Support for CDR Programs by Total Full Time Equivalent Staff Positions (FTEs) 13

8. States with Legislation or Administrative Rules for State CDR Program ........................... 14

9. Level of Statute/Administrative Rules for State CDR Team by State ................................ 14

10. States with Legislation or Administrative Rules for Local CDR Teams .............................. 15

11. Level of Statute or Administrative Rules for Local CDR Team by State ............................. 15

12. States with Selected Items Covered in State Statute or Administrative Rules ................. 16

13. Selected Protocols in Place by State .................................................................................. 16

SECTION B: THE REVIEW PROCESS........................................................................................ 18

14. Where In-Depth Case Review Occurs ................................................................................ 19

15. Where In-Depth Case Review Occurs by State .................................................................. 19

16. Types of Deaths Reviewed in States .................................................................................. 20

17. States with CDR Review of Serious Injuries or Near Fatalities .......................................... 20

18. Maximum Age of Child Deaths Reviewed by State ........................................................... 21

19. Timing of Reviews .............................................................................................................. 21

20. Average Time Between Death and Review, in Months by State ....................................... 21

21. Percent of States that Provide Annual CDR Training ......................................................... 22

22. Percent of States with a Case Identification Process ........................................................ 22

23. State Level Advisory Boards ............................................................................................... 23

24. Functions of State Advisory Board ..................................................................................... 23

25. Entity to Whom State Advisory Board Makes Recommendations .................................... 24

26. Percent of States that Require a Response to CDR Advisory Board’s Recommendations 24

27. Types of State Advisory Board Recommendations Made at the State Level .................... 25

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28. Percent of States Where a Team Member has Ever Been Subpoenaed for Case Review Information ............................................................................................................................... 25

29. Percent of States Where Deaths under Active Investigation by Law Enforcement Are Reviewed by CDR ...................................................................................................................... 26

30. Percent of States Where Deaths under Civil Litigation are Reviewed by CDR .................. 26

SECTION C: CDR REPORTING ................................................................................................ 27

31. Types of Reporting Systems Used by States ...................................................................... 28

32. Average Time Between Review and Data Entry in Months by State ................................. 28

33. Percent of States Producing Reports Using Their CDR Data .............................................. 29

34. Percent of States Producing Annual Report Releasing Report to Specific Entities ........... 29

35. Percent of States Producing Annual Report Where an Official Response Is Required ..... 30

SECTION D: COORDINATION WITH OTHER REVIEWS ............................................................. 31

36. Number of States with Other Review Processes ............................................................... 32

37. Where CDR Serves as the CAPTA Citizen Review Panel (CRP) by State ............................. 32

38. Number of States that Have Another Child Abuse and Neglect Death Review System .... 33

39. Percent of States That Conduct Internal Agency Reviews of Child Deaths ....................... 33

40. Percent of States with Military Participation on CDR Teams ............................................ 33

41. Percent of States with CDR Participation on Military CDR Teams..................................... 34

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SECTION A: CDR PROGRAM ADMINISTRATION

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1. State Agency That Leads Coordination of CDR Program

2. State Agency That Leads Coordination of CDR Program by State

State Name

Alabama Health Department, Alabama Department of Public Health, Bureau of Prevention, Promotion, and Support

Alaska Health Department, Section of Women's, Children's, & Family Health, Division of Public Health

Arizona Health Department, Prevention Health Services/Bureau of Women’s and Children’s Health/Office of Injury Prevention

Arkansas Other, Arkansas Children’s Hospital Injury Prevention Center

California Health Department, Public Health Department, Safe and Active Communities (SAC) Branch

Colorado Health Department, Prevention Services Division - Violence and Injury Prevention-Mental Health Promotion Branch

Connecticut Other, Office of the Child Advocate

Delaware Other, Administrative Offices of the Court

District of Columbia

Medical Examiner

Florida Health Department, Division of Children’s Medical Services

Georgia Other, Georgia Bureau of Investigation

Hawaii Health Department, Maternal and Child Health Branch

Idaho Health Department, Bureau of Family and Community Services

Illinois Social Services

Indiana Health Department, Health and Human Services Commission of the Indiana State Department of Health

Iowa Health Department, Iowa Office of the State Medical Examiner

11.8%

5.9%

7.8%

17.6%

56.9%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Other (n=6)

Attorney General, DOJ (n=3)

Medical Examiner (n=4)

Social Services (n=9)

Health Department (n=29)

Percent of responses

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Kansas Attorney General, DOJ

Kentucky Health Department, Maternal and Child Health

Louisiana Health Department, LDH-OPH-Bureau of Family Health

Maine Health Department, Office of Child and Family Services, DHHS

Maryland Health Department, Maternal and Child Health Bureau

Massachusetts

Medical Examiner

Michigan Social Services

Minnesota Social Services

Mississippi Health Department, Health Services

Missouri Social Services

Montana Health Department, MT Dept of Public Health & Safety Division, Family and Community Health Bureau

Nebraska Health Department, Nebraska Department t of Health & Human Services Division of Public Health

Nevada Social Services, Division of Child and Family Services: Child Welfare

New Hampshire

Attorney General, DOJ

New Jersey Social Services

New Mexico Health Department, Epidemiology and Response Division, Injury and Behavioral Epidemiology Bureau

New York Social Services

North Carolina

Medical Examiner

North Dakota Social Services

Ohio Health Department, Maternal, Child and Family Health

Oklahoma Other, The Oklahoma Commission on Children and Youth

Oregon Health Department, state public health division

Pennsylvania Health Department

Rhode Island Health Department, Office of State Medical Examiner (within Health Department)

South Carolina

Health Department, Division of Injury and Violence Prevention

South Dakota Health Department, Office of Child and Family Services

Tennessee Health Department, Division of Family Health and Wellness

Texas Health Department, Office of Injury Prevention in the Community Health Improvement Division

Utah Health Department, Division of Disease Control and Prevention, Violence and Injury Prevention Program

Vermont Other: In November, 2017, the CFRT approved a new set of operational guidelines (bylaws) which established the positions of Chair and Vice Chair and the Vermont Department of Health assumed a more prominent role in the coordination of Vermont’s Child Fatality Review team.

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Virginia Health Department, Office of the Chief Medical Examiner

Washington Health Department, Office of Healthy Communities

West Virginia Medical Examiner

Wisconsin Health Department, Maternal Child Health Division

Wyoming Social Services

3. Type of State CDR Coordination and Program Support

4. CDR Coordination with Other State Programs

35.3%

51.0%

68.6%

72.5%

78.4%

90.2%

96.1%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Other functions (n=18)

Coordination of Local Teams (n=26)

Training for Local Teams (n=35)

Technical Assistance to Local Teams (n=37)

Develop Recommendations (n=40)

Coordination of State Team (n=46)

Data Collection and Reporting (n=49)

Percent of responses*Responses are not mutually exclusive

88.2%

94.1%

100.0%

0% 20% 40% 60% 80% 100%

State Injury Prevention (n=45)

State Maternal Child Health Program (n=48)

State Child Protective Services (n=51)


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5. Annual Funds Allocated Specifically for CDR Programs by State Median Funding Amount (37 states): $119,814

Note: Some states list zero dollars. This reflects that no funds are directly allocated to the program, although CDR is supported by a state agency through the funding of other programs. States that reported zero dollars were not included in the calculation of the median funding amount.

State Annual Budget State Annual Budget Alabama $300,000 Missouri $764,000 Alaska $155,000 Montana $70,000 Arizona $322,700 Nebraska $100,000 Arkansas $182,900 Nevada $119,814 California $150,000 New Hampshire $2,000 Colorado $625,000 New Jersey U/K Connecticut $150,000 New Mexico $150,000 Delaware $445,500 New York $829,100 District of Columbia $386,955 North Carolina $200,000 Florida $31,000 North Dakota $1,000 Georgia $0 Ohio $150,000 Hawaii $0 Oklahoma $176,975 Idaho $50,000 Oregon $0 Illinois $107,500 Pennsylvania $193,520 Indiana $0 Rhode Island U/K Iowa $0 South Carolina $100,000 Kansas $158,225 South Dakota $42,000 Kentucky $418,500 Tennessee $225,000 Louisiana U/K Texas $140,000 Maine $102,000 Utah $30,000 Maryland* $1,200,000 Vermont $6,500 Massachusetts $0 Virginia $75,000 Michigan $639,000 Washington $35,912 Minnesota $465,000 West Virginia U/K Mississippi $25,000 Wisconsin $220,000 Wyoming $10,000

*Includes both CDR and FIMR, not used in determining the median funding

6. Type and Source of Funding Allocated for CDR Programs by State

State Type of Federal Funds Type of State Funds Other Funds Alabama Medicaid Reimbursement

Agreement Tobacco Settlement

Alaska MCH Block Grant; CDC SUID grant

Arizona MCH Block Grant; CDC SUID Case Registry Grant

General state funds One dollar surcharge on death certificates

Arkansas Contract with ADH Family Health Branch

California MCH Block Grant

Colorado CDC grant for SUID Case Registry

Colorado General Fund dollars

Connecticut State appropriations-General funds

Delaware SDY funds from CDC State appropriations-General funds, grant monies, community partners

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State Type of Federal Funds Type of State Funds Other Funds District of Columbia

DC appropriations-General funds

Florida State appropriations-General funds

Local health and social services

Georgia CDC SDY grant State appropriations-General funds

Hawaii DOH

Idaho CAPTA and CJA

Illinois DCFS funds

Indiana

Iowa

Kansas

Kentucky MCH Title V Block Grant State appropriations-General funds

Louisiana Federal Title V MCH Block Grant

Maine Children's Justice Act

Maryland MCH Block Grant MCH state match

Massachusetts

Michigan CAPTA State appropriations-General funds

Minnesota Title IVB.1

Mississippi MCH Block Grant

Missouri E&E budget, personal services and general funds

Grants

Montana MCH Block Grant State appropriations-General funds

Nebraska MCH Block Grant

Nevada Death certificate fees

New Hampshire Children's Justice Act Administrative support

New Jersey Grants

New Mexico MCH Block grant, federal prevention block grant, SUID grant

General funds

New York Office of Children and Family Services

North Carolina Yes, unknown type

North Dakota Yes, unknown type Yes, unknown type

Ohio MCH Block Grant

Oklahoma Line item for Oklahoma Commission on Children and Youth's Annual Budget

Oregon

Pennsylvania SUID Case Registry Grantee Department of Health

Rhode Island Title V Rhode Island Department of Health

South Carolina Department of Social Services

South Dakota MCH Block Grant

Tennessee MCH Block Grant and SDY Registry funds

Related MCH Block Grant Match

Texas MCH Block Grant Texas Department of State Health Services

Utah MCH Block Grant and Department of Human Services, DCFS

Vermont Children's Justice Act Occasional grant support; currently CJA

Virginia MCH Block Grant

13

State Type of Federal Funds Type of State Funds Other Funds Washington MCH Block Grant Local CDR Coordinators are funded

by a variety of funds. There is not a CDR specific funding source in WA

West Virginia State appropriations-General funds

Wisconsin Children's Justice Act, CDC Case Registry

Title V funding Children's Hospital of Wisconsin, Inc.

Wyoming Children's Justice Act – says “CAPTA filters through the state to the WY CRP via contract”

Yes, unknown type

7. Paid Staff Support for CDR Programs by Total Full Time Equivalent Staff

Positions (FTEs) State median number FTE, including both paid and in-kind staff: 1.50 FTE

Note: Zero does not mean that no person is designated to coordinate the program. All states have a designated

coordinator, but there may not be a designated and funded FTE for the CDR program.

State State Staff (FTEs)

In Kind Staff (FTEs)

State State Staff (FTEs)

In Kind Staff (FTEs

Alabama 3.0 0 Missouri 14.5 0 Alaska 1.5 0 Montana 1.0 0.25 Arizona 1.5 0 Nebraska 1.35 0.15 Arkansas 1.4 0 Nevada 0 1.5 California 0 10.0 New Hampshire 0 0 Colorado 3.0 0.5 New Jersey 0 4.0 Connecticut 1.5 0.5 New Mexico 1.0 0.75 Delaware 5.0 0 New York 1.0 0 DC 3.0 0 North Carolina 2.0 0 Florida 3.0 0 North Dakota 0 0.2 Georgia 4.0 2.0 Ohio 1.25 0 Hawaii 1.0 4.0 Oklahoma 1.0 0 Idaho 0.5 0 Oregon 0 1.0 Illinois 1.5 1.0 Pennsylvania 1.75 0 Indiana 2.0 0 Rhode Island 0.4 0 Iowa 0 0 South Carolina 1.0 0 Kansas 2.0 0 South Dakota 0.25 0.1 Kentucky 1.0 0.5 Tennessee 1.75 0.0 Louisiana 1.0 1.0 Texas 1.0 0.15 Maine 1.0 2.0 Utah 0.75 2.5 Maryland 1.5 0 Vermont 0 0.05 Massachusetts 0.5 0.5 Virginia 1.0 0 Michigan 4.9 0 Washington 0.15 0 Minnesota 4.5 0 West Virginia 2.0 1.0 Mississippi 0 0.3 Wisconsin 2.7 3.0 Wyoming 0 1.5

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8. States with Legislation or Administrative Rules for State CDR Program

9. Level of Statute/Administrative Rules for State CDR Team by State

State State CDR Team Statute/Rules

State State CDR Team Statute/Rules

Alabama Mandated Missouri Mandated Alaska None/Mandated* Montana None Arizona Mandated Nebraska Mandated Arkansas Mandated Nevada Mandated California Permitted New Hampshire Permitted Colorado Mandated New Jersey Mandated Connecticut Mandated New Mexico Mandated Delaware Mandated New York None District of Columbia Mandated North Carolina Mandated Florida Mandated North Dakota Mandated Georgia Mandated Ohio Permitted Hawaii Permitted Oklahoma Mandated Idaho None Oregon Mandated Illinois Mandated Pennsylvania Mandated Indiana Mandated Rhode Island Permitted Iowa Mandated South Carolina Mandated Kansas Mandated South Dakota None Kentucky Permitted Tennessee Mandated Louisiana Mandated Texas Mandated Maine Permitted Utah Permitted Maryland Mandated Vermont Permitted Massachusetts Mandated Virginia Mandated Michigan Mandated Washington None Minnesota Mandated West Virginia Mandated Mississippi Mandated Wisconsin None Wyoming Mandated

11.8%

17.6%

70.6%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

None (n=6)

Permits State CDR (n=10)

Mandates State CDR (n=35)


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*Alaska has two review processes. One is mandated at the Medical Examiner’s Office and reviews possible child maltreatment deaths. The other reviews preventable deaths and is not mandated; it is operated out of the Health Department.

10. States with Legislation or Administrative Rules for Local CDR Teams

11. Level of Statute or Administrative Rules for Local CDR Team by State

State Local CDR Team Statute/Rules


Alabama Mandated Missouri Mandated Alaska None Montana Mandated Arizona Permitted Nebraska None Arkansas Permitted Nevada Permitted California Permitted New Hampshire None Colorado Mandated New Jersey Permitted Connecticut None New Mexico None Delaware Mandated New York Permitted District of Columbia None North Carolina Mandated Florida Mandated North Dakota None Georgia Mandated Ohio Mandated Hawaii Permitted Oklahoma Permitted Idaho None Oregon Mandated Illinois Mandated Pennsylvania Mandated Indiana Mandated Rhode Island None Iowa None South Carolina Permitted Kansas None South Dakota None Kentucky Permitted Tennessee Mandated Louisiana Permitted Texas Permitted Maine None Utah None Maryland Mandated Vermont None Massachusetts Mandated Virginia Permitted

37.3%

33.3%

29.4%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

None (n=19)

Mandates Local CDR (n=17)

Permits Local CDR (n=15)


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Michigan Permitted Washington Permitted Minnesota Mandated West Virginia None Mississippi None Wisconsin None Wyoming None

12. States with Selected Items Covered in State Statute or Administrative Rules

13. Selected Protocols in Place by State

State CDR Meeting Protocol

Child/Infant Death Investigation

Protocol

Confidentiality Protocol

Other Protocols

Alabama X X X

Alaska X X X

Arizona X X X X

Arkansas X X X

California X X X

Colorado X X

Connecticut X X X

39.2%

43.1%

45.1%

49.0%

58.8%

72.5%

72.5%

76.5%

78.4%

80.4%

84.3%

84.3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Review protocol (n=20)

Case review report (n=22)

Local Teams (n=23)

Defines required local team members (n=25)

Review not subject to FOIA (n=30)

CDR program report (n=37)

Defines required state team members (n=37)

Meetings not open to public (n=39)

Review protected from subpoena/discovery (n=40)

State Team (n=41)

Access to child’s records(n=43)

Meetings are confidential (n=43)


17

State CDR Meeting Protocol

Child/Infant Death Investigation

Protocol

Confidentiality Protocol

Other Protocols

Delaware X X X

District of Columbia X X X X

Florida X X X

Georgia X X X

Hawaii X X X

Idaho X

Illinois X X

Indiana X X X

Iowa X X X

Kansas X X X

Kentucky X X X

Louisiana X X X

Maine X X X X

Maryland X X X

Massachusetts X X X X

Michigan X X X

Minnesota X X X

Mississippi X X

Missouri X X X

Montana X X X

Nebraska X X X

Nevada X X

New Hampshire X X X

New Jersey X X X

New Mexico X

New York

North Carolina X X X

North Dakota X X

Ohio X X X

Oklahoma X X

Oregon X X X

Pennsylvania X

Rhode Island X X X X

South Carolina X X X

South Dakota X

Tennessee X X X

Texas X X X

Utah X X X X

Vermont X X

Virginia X X

Washington X

West Virginia X X X

Wisconsin X X X .

Wyoming X X X

Number of States 44 37 50 7

18

SECTION B: THE REVIEW PROCESS

19

14. Where In-Depth Case Review Occurs

15. Where In-Depth Case Review Occurs by State

State Local Review

State Review

State Local Review

State Review

Alabama X X Missouri X X

Alaska X Montana X

Arizona X Nebraska X X

Arkansas X Nevada X

California X New Hampshire X

Colorado X X New Jersey X X

Connecticut X New Mexico X

Delaware X X New York X

DC X North Carolina X X

Florida X X North Dakota X

Georgia X X Ohio X

Hawaii X Oklahoma X X

Idaho X Oregon X X

Illinois X Pennsylvania X

Indiana X X Rhode Island X

Iowa X X South Carolina X X

Kansas X South Dakota X

Kentucky X X Tennessee X

Louisiana X X Texas X

Maine X Utah X

Maryland X Vermont X

Massachusetts X Virginia X X

Michigan X Washington X

Minnesota X X West Virginia X

Mississippi X Wisconsin X

Wyoming X

29.4%

35.3%

35.3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

State review only (n=15)

Local review only (n=18)

State and local review (n=18)


20

16. Types of Deaths Reviewed in States

Responses are not mutually exclusive for both Type of Death and Local/State level of Team. Fifteen states review 100% of child deaths.

Type of Death Local Review (n=36)

State Review (n = 33)

Medical Deaths (not SIDS but includes infections, asthma, cardiac, cancer, etc.)

25 16

SIDS 34 28

SUID (SIDS, suffocation and undetermined infant deaths) 34 30

Unintentional Injuries 33 28

Homicides 32 27

Suicides 31 28

Undetermined 33 27

Abuse and Neglect 33 32

Opioid 28 21

Current or History of contact with Social Services 29 28

Child was a ward of the state 27 28

Child was a resident of another state/jurisdiction and death occurred in this state/jurisdiction

23 21

Child’s death occurred in a different state/jurisdiction and the child was a resident of this state/jurisdiction

17 12

17. States with CDR Review of Serious Injuries or Near Fatalities

Number of States with Local Teams=36 Number of States with State Teams=33

13.7%

19.6%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

At Local Level (n=7)

At State Level (n=10)


21

18. Maximum Age of Child Deaths Reviewed by State

Minimum age: 14; maximum age: 25

State Age State Age State Age Alabama 17 Kentucky 17 North Dakota 17

Alaska 17 Louisiana 14 Ohio 17

Arizona 17 Maine 17 Oklahoma 17

Arkansas 17 Maryland 17 Oregon 17

California 17 Massachusetts 17 Pennsylvania 21

Colorado 17 Michigan 18 Rhode Island 17

Connecticut 17 Minnesota 17 South Carolina 17

Delaware 17 Mississippi 17 South Dakota 17

DC 23 Missouri 17 Tennessee 17

Florida 17 Montana 17 Texas 17

Georgia 17 Nebraska 17 Utah 18

Hawaii 17 Nevada 18 Vermont 18

Idaho 17 New Hampshire 18 Virginia 17

Illinois 17 New Jersey 17 Washington 17

Indiana 17 New Mexico 17 West Virginia 17

Iowa 17 New York 17 Wisconsin 25

Kansas 17 North Carolina 17 Wyoming 17

19. Timing of Reviews

Responses are not mutually exclusive.

Timing of Review Local Review State Review Retrospective/Periodic 33 33

Immediate Response (48 Hours) 4 0

20. Average Time Between Death and Review, in Months by State

State Local Review: Time, in Months

State Review: Time, in Months



Alabama 15 9 Missouri 3 36

Alaska N/A 8 Montana 7 N/A

Arizona 6 N/A Nebraska 4 36

Arkansas 15 N/A Nevada 3 N/A

California 4 N/A New Hampshire N/A 4

Colorado 5 18 New Jersey 11 11

Connecticut N/A 2 New Mexico N/A 12

Delaware 3 6 New York 1 N/A

DC N/A 8 North Carolina 12 12

Florida 12 12 North Dakota N/A 7

Georgia 3 6 Ohio 6 N/A

Hawaii 12 N/A Oklahoma 15 15

Idaho N/A 18 Oregon 8 12

Illinois 6 N/A Pennsylvania 6 N/A

Indiana 3 9 Rhode Island N/A 6

22





Iowa U/K 11 South Carolina 6 12

Kansas N/A 1 South Dakota 4 N/A

Kentucky 3 6 Tennessee 3 N/A

Louisiana 3 4 Texas 18 N/A

Maine N/A 3 Utah N/A 1

Maryland 3 N/A Vermont N/A 12

Massachusetts U/K N/A Virginia 12 42

Michigan 3 N/A Washington 9 N/A

Minnesota 6 6 West Virginia N/A 24

Mississippi N/A 12 Wisconsin 3 N/A

Wyoming N/A 12

21. Percent of States that Provide Annual CDR Training

22. Percent of States with a Case Identification Process

62.7%

37.3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Yes (n=32)

No (n=19)


2.0%

98.0%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

No (n=1)

Yes (n=50)


23

23. State Level Advisory Boards N = 43

State Has Advisory

Board

State Has Advisory

Board

State Has Advisory

Board

Alabama X Kentucky X North Dakota

Alaska X Louisiana X Ohio X

Arizona X Maine X Oklahoma X

Arkansas X Maryland X Oregon X

California Massachusetts X Pennsylvania X

Colorado X Michigan X Rhode Island X

Connecticut X Minnesota X South Carolina X

Delaware X Mississippi X South Dakota X

DC X Missouri X Tennessee X

Florida X Montana Texas X

Georgia X Nebraska X Utah X

Hawaii X Nevada X Vermont X

Idaho X New Hampshire Virginia X

Illinois X New Jersey X Washington

Indiana X New Mexico West Virginia X

Iowa X New York Wisconsin X

Kansas North Carolina X Wyoming X

24. Functions of State Advisory Board

(by percent of 43 States)

55.8%

65.1%

72.1%

97.7%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Conduct state reviews (n=24)

Review local findings (n=28)

Write annual reports (n=31)

Make formal recommendations (n=42)


24

25. Entity to Whom State Advisory Board Makes Recommendations (by percent of 42 states that make formal recommendations)

26. Percent of States that Require a Response to CDR Advisory Board’s Recommendations

(of 42 States who make formal recommendations)

52.4%

57.1%

66.7%

78.6%

88.1%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Local Teams (n=22)

General Public (n=24)

Governor (n=28)

Legislature (n=33)

State Agency(s) (n=37)

Percent

23.8%

76.2%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Yes (n=10)

No (n=32)


*Responses are not mutually exclusive

25

27. Types of State Advisory Board Recommendations Made at the State Level (by percent of 42 states that reported they make formal recommendations)

28. Percent of States Where a Team Member has Ever Been Subpoenaed for Case Review Information

85.7%

88.1%

88.1%

92.9%

95.2%

97.6%

75% 80% 85% 90% 95% 100%

Improvement of Individual Knowledge and Skills (n=36)

Amendment/Enactment of Policy Legislation (n=37)

Improvement of Organizational Practices (n=37)

Provider Education (n=39)

Strengthening Collaboration Among Agencies (n=40)

Community Education (n=41)

Percent*Responses are not mutually exclusive

2.0%

9.8%

88.2%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Unknown (n=1)

Yes (n=5)

No (n=45)


26

29. Percent of States Where Deaths under Active Investigation by Law Enforcement Are Reviewed by CDR

Number of States with Local Teams=36 Number of States with State Teams=33

30. Percent of States Where Deaths under Civil Litigation are Reviewed by CDR Number of States with Local Teams=36 Number of States with State Teams=33

48.5%

52.8%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%




61.1%

63.6%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%




27

SECTION C: CDR REPORTING

28

31. Types of Reporting Systems Used by States

32. Average Time Between Review and Data Entry in Months by State





Alabama 15 9 Missouri N/A U/K

Alaska N/A 1 Montana 3 N/A

Arizona 1 N/A Nebraska U/K 24

Arkansas 1 N/A Nevada 6 N/A

California 12 N/A New Hampshire N/A 2

Colorado 6 1 New Jersey 1 1

Connecticut N/A 6 New Mexico N/A 8.5

Delaware 4.5 4.5 New York 1 N/A

DC N/A 8 North Carolina 12 12

Florida 1 U/K North Dakota N/A 7

Georgia 3 U/K Ohio 1 N/A

Hawaii 2 N/A Oklahoma 9 9

Idaho N/A 1 Oregon 8 U/K

Illinois 1 N/A Pennsylvania 6 N/A

Indiana 1 U/K Rhode Island N/A U/K

Iowa U/K 1 South Carolina U/K 12

Kansas N/A 0 South Dakota 1.5 N/A

Kentucky 3 3 Tennessee 0 N/A

Louisiana 1 U/K Texas 11 N/A

Maine N/A 0 Utah N/A 1

Maryland 3 N/A Vermont N/A U/K

Massachusetts 19 N/A Virginia 3 6

Michigan 6 N/A Washington 12 N/A

Minnesota U/K 6 West Virginia N/A 2

Mississippi N/A 15 Wisconsin 1 N/A

Wyoming N/A 12

3.9%

9.8%

86.3%

0% 20% 40% 60% 80% 100%

None (n=2)

State database (n=5)

National Fatality Review Case Reporting System (n=44)


29

33. Percent of States Producing Reports Using Their CDR Data

34. Percent of States Producing Annual Report Releasing Report to Specific Entities (n=43)

54.9%

84.3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Other reports based on CDR Finding (n=28)

Annual Report (n=43)


65.1%

76.7%

86.0%

86.0%

93.0%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Local teams (n=28)

Governor (n=33)

Legislature (n=37)

State Agencies (n=37)

General public (n=40)


30

35. Percent of States Producing Annual Report Where an Official Response Is Required

(n=43)

11.6%

88.4%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Yes (n=5)

No (n=38)


31

SECTION D: COORDINATION WITH OTHER REVIEWS

32

36. Number of States with Other Review Processes Responses are not mutually exclusive.

Type of Review Other Review Process in Place

CDR Coordinates with Other Review Processes

Citizen Review Panels 43 24

FIMR 31 26

Domestic Violence 33 20

Maternal Mortality 34 25

Other SIDS Reviews 18 12

Specialized Review System for CPS 38 27

Suicide 6 6

Homicide 5 3

Other 14 9

37. Where CDR Serves as the CAPTA Citizen Review Panel (CRP) by State

Number of States: 16

State Serves as CRP State Serves as CRP Alabama Missouri X

Alaska Montana

Arizona Nebraska

Arkansas Nevada

California New Hampshire

Colorado New Jersey X

Connecticut New Mexico

Delaware New York

District of Columbia North Carolina

Florida X North Dakota X

Georgia X Ohio

Hawaii Oklahoma X

Idaho Oregon

Illinois X Pennsylvania

Indiana X Rhode Island

Iowa South Carolina X

Kansas X South Dakota

Kentucky Tennessee

Louisiana Texas X

Maine Utah

Maryland X Vermont

Massachusetts Virginia X

Michigan X Washington

Minnesota West Virginia

Mississippi Wisconsin X

Wyoming X

33

38. Number of States that Have Another Child Abuse and Neglect Death Review System N = 35

Types of Secondary CAN review Number of States Local child welfare agency conducts internal review of child abuse and neglect deaths 26

Separate multidisciplinary state team which reviews only child abuse and neglect deaths

15

State child welfare agency conducts internal review of child abuse and neglect deaths 9

Separate multidisciplinary local teams which review only child abuse and neglect deaths

8

Subcommittee of the state CDR team conducts specialized reviews of child abuse and neglect deaths

7

Other 5

39. Percent of States That Conduct Internal Agency Reviews of Child Deaths

40. Percent of States with Military Participation on CDR Teams Number of States with Local Teams=36 Number of States with State Teams=33

7.8%

92.2%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

No (n=4)

Yes (n=47)


6.1%

30.6%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%




34

41. Percent of States with CDR Participation on Military CDR Teams Number of States with Local Teams=36 Number of States with State Teams=33

6.1%

16.7%

0% 2% 4% 6% 8% 10% 12% 14% 16% 18%




Percent of States CDR Participation on Military CDR Teams

Documents

Keeping Kids Alive: A Report on the Status of Child Death ... · Trends in Child Death Review The most notable indicator of growth of the CDR system is that today there are more than